Provider Demographics
NPI:1730289810
Name:LISENBY, HEATH K (DMIN, LMHC)
Entity Type:Individual
Prefix:DR
First Name:HEATH
Middle Name:K
Last Name:LISENBY
Suffix:
Gender:M
Credentials:DMIN, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6322 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1518
Mailing Address - Country:US
Mailing Address - Phone:260-203-0294
Mailing Address - Fax:260-264-4581
Practice Address - Street 1:6322 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-203-0294
Practice Address - Fax:260-264-4581
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001625A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200530260AMedicaid